Provider Demographics
NPI:1639994205
Name:BRYANT, MASON DOUGLAS
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:DOUGLAS
Last Name:BRYANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 55TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-5043
Mailing Address - Country:US
Mailing Address - Phone:619-493-0077
Mailing Address - Fax:
Practice Address - Street 1:2755 55TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5043
Practice Address - Country:US
Practice Address - Phone:619-493-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician